Hospice eligibility guidelines: dementia

What are the hospice eligibility indicators for dementia?

Hospice eligibility for dementia under the Medicare LCD guidance requires both parts: a functional stage of FAST 7 or beyond, and at least one complicating condition in the past 12 months, such as aspiration pneumonia, upper urinary tract infection, septicemia, multiple stage 3 to 4 pressure ulcers, recurrent fever or inadequate intake.

Read this table together with the general decline indicators and the non-disease-specific baseline (functional status and dependence in activities of daily living) on the eligibility guidelines overview.

FAST stage 7 substages

FAST stage 7 is divided into substages 7a to 7f, from speech limited to about half a dozen intelligible words (7a) to being unable to hold the head up independently (7f).

FAST is ordinal and was validated in Alzheimer's disease. Stages should be reached in sequence. In vascular, Lewy body and mixed dementias, patients often skip stages, so FAST is less reliable and comorbidities and complications carry more of the prognostic weight. For how the LCD treats substages, see the LCD.

What documentation supports hospice eligibility in dementia?

Documentation that supports hospice eligibility in dementia includes the items below. Send or note what you have. None of these is required to make a referral.

• The type of dementia, approximate onset, and the FAST stage with the specific findings behind it.
• Weights over the past six to twelve months, with percent change, and current intake described in portions.
• Swallowing problems: coughing with meals, pocketing food, texture changes, speech-language pathology findings.
• Infections, hospitalizations and emergency visits in the past 12 months, with dates.
• Skin condition and any pressure injuries.
• Whether the family has decided for or against a feeding tube, hospital transfer and antibiotics.
• PPS or KPS score if available.

Can a patient with dementia below FAST 7 be eligible for hospice?

Many patients with dementia who die within six months never reach FAST 7c or beyond. A patient at FAST 6 with heart failure, recurrent pneumonia and steady weight loss may have a prognosis of six months or less. In that case the record should explain why, in specific terms. The terminal diagnosis may also be better described by another condition with dementia as a comorbidity.

The Medicare hospice LCD guidance weighs comorbidities as well as the primary diagnosis. The presence and severity of conditions such as chronic obstructive pulmonary disease, congestive heart failure, ischemic heart disease, diabetes, neurologic disease (stroke, ALS, multiple sclerosis, Parkinson's disease), renal failure, liver disease, malignancy, AIDS and dementia can support a prognosis of six months or less even when the primary diagnosis alone does not. Document each one with its current severity and how it limits the patient.

What if you are not sure a patient is eligible for hospice?

If you are not sure a patient is eligible for hospice, call Beta Hospice and talk the case through with a hospice nurse, or ask for a physician-to-physician conversation with our medical director. A call is not a referral and does not commit the patient to anything. Dementia has the least predictable course of the common hospice diagnoses. Prognosis is rarely clear cut.

If the patient is not hospice eligible now, we will say so and tell you what we would watch for. Some patients are better served by palliative care first. When you are ready, use Refer a patient. The hospice medical director, with the attending physician if there is one, makes the certification decision under 42 CFR 418.22.

A page you can share with the family

Beta Hospice's family guide, hospice care for dementia, explains in plain language what hospice does for this illness, what signs are worth raising with a doctor or nurse, and how care is paid for. It does not give an eligibility verdict. Families often ask the same questions you are weighing, in different words. You are welcome to share it before or after a goals-of-care conversation.

Related guides

When to call hospice for dementia and adult failure to thrive guidelines.